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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
286802049
Report Date:
10/24/2023
Date Signed:
10/24/2023 01:18:38 PM
Document Has Been Signed on
10/24/2023 01:18 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
ADMINISTRATOR:
ROA, FRANCISCO
FACILITY TYPE:
740
ADDRESS:
2541 VINTAGE STREET
TELEPHONE:
(707) 265-8652
CITY:
NAPA
STATE:
CA
ZIP CODE:
94558
CAPACITY:
6
CENSUS:
DATE:
10/24/2023
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
Caregiver Catalina Sanchez
TIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Victoria Bertozzi arrived unannounced to conduct an Annual Required inspection and was greeted by staff. Administrator, Francisco Roa was unable to come to facility but was available by phone and gave permission for staff to sign report.
LPA initiated a tour of the facility around 10:30am and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. Water temperature in bathroom used by residents measured at 108.6 degrees F which is within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked. Facility has at least two days of perishable and one week of non-perishable foods which appeared to be of quality and stored per regulation. Medications were centrally stored and locked. Facility does not have adequate emergency food and no emergency water supplies.
Fire extinguishers were last serviced August 2023. Smoke and Carbon Monoxide detectors located throughout the facility were tested and operational during inspection.
Four staff files and four resident files were reviewed. Staff do not have required First Aid and CPR certificates or updated training records. Administrator Certificate for Administrator, Francisco Roa, 6005473740 is on the Department's pending list. Medication records were reviewed.
Continued on LIC 809C
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809
(FAS) - (06/04)
Page:
1
of
7
Document Has Been Signed on
10/24/2023 01:18 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c) The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four caregivers not having current First Aid and CPR Certificate which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
10/25/2023
Plan of Correction
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Licensee agrees to schedule CPR and First Aid training for staff immediately and provide planned training dates to CCL by POC due date, 10/24/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
2
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Document Has Been Signed on
10/24/2023 01:18 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(b)(2)(C)
Infection Control Requirements
(b) In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE) to prevent exposure to infectious agents or chemicals through the respiratory system, skin, or mucous membranes of the eyes, nose, or mouth. PPE may include gloves, gowns, masks, respirators, shoe coverings and eye protection. (C) The licensee shall ensure all staff and volunteers are trained in the proper use of all required PPE prior to being around residents and annually thereafter.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four caregivers not having required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/24/2023
Plan of Correction
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Licensee agrees to have all staff trained to meet regulation and submit proof of training to CCL no later than POC due date, 11/24/2023.
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in four out of four caregivers not having required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/24/2023
Plan of Correction
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Licensee agrees to have all staff trained to meet regulationa and submit proof of training to CCL no later than POC due date, 11/24/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
3
of
7
Document Has Been Signed on
10/24/2023 01:18 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:
This requirement is not met as evidenced by:
Deficient Practice Statement
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3
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Based on record review, the licensee did not comply with the section cited above in four out of four caregivers not having required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/24/2023
Plan of Correction
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Licensee agrees to have all staff trained to meet regulation and submit proof of training to CCL no later than POC due date, 11/24/2023.
Type B
Section Cited
CCR
87456(a)(2)
Evaluation of Suitability for Admission
(a) Prior to accepting a resident for care and in order to evaluate his/her suitability, the facility shall, as specified in this article 8: (2) Perform a pre-admission appraisal.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 1 out of 4 residents not having a pre-admission appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/31/2023
Plan of Correction
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Licensee agrees to complete a Preadmission Appraisal for resident, R1 and submit copy to CCL no later than due date, 10/31/2024.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
4
of
7
Document Has Been Signed on
10/24/2023 01:18 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above in 3 out of 4 residents not having updated reappraisals which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/31/2023
Plan of Correction
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Licensee agrees to reassess R2, R3 and R4, complete a reappraisal for each and submit reappraisals to CCL no later than POC due date, 10/31/2023.
Type B
Section Cited
CCR
87468(c)(2)(A)
(c) Licensees shall prominently post personal rights, nondiscrimination notice, & complaint information in areas accessible to residents, representatives, & the public. (2) Information on the appropriate reporting agency in case of a complaint or emergency, including procedures for filing confidential complaints, shall be posted as follows: (A) Licensees may use the RCFE Complaint Poster (PUB 475) or may develop their own poster as provided in this section. A poster developed by the licensee shall contain the same content as the PUB 475. The poster that is posted shall be 20” x 26” in size and be posted in the main entryway of the facility. PUB 475 may be accessed, downloaded, and printed from the www.ccld.ca.gov website.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having complaint poster posted per regulation which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/31/2023
Plan of Correction
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Licensee agrees to post the CCL Complaint Poster per regulation and submit a picture showing the poster is in the main entryway no later than POC due date, 10/31/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
5
of
7
Document Has Been Signed on
10/24/2023 01:18 PM
- It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE:
10/24/2023
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(b)
Other Provisions
(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above in four out of four caregivers not having required training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
11/24/2023
Plan of Correction
1
2
3
4
Licensee agrees to have all staff trained to meet regulation and submit proof of training to CCL no later than POC due date, 11/24/2023.
Type B
Section Cited
HSC
1569.695(a)(2)
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (2) Plans for the facility to be self-reliant for a period of not less than 72 hours immediately following any emergency or disaster, including, but not limited to, a short-term or long-term power failure. If the facility plans to shelter in place and one or more utilities, including water, sewer, gas, or electricity, is not available, the facility shall have a plan and supplies available to provide alternative resources during an outage.
This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above by not having adequate emergency food and water supply which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
10/31/2023
Plan of Correction
1
2
3
4
Licensee agrees to obtain needed emergency supplies per their Emergency Disaster Plan and submit picture(s) of supply no later than POC due date, 10/31/2023.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
6
of
7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO
,
1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA
,
CA
95405
FACILITY NAME:
VINTAGE HOUSE
FACILITY NUMBER:
286802049
VISIT DATE:
10/24/2023
NARRATIVE
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Continued from LIC 809
Licensee/Administrator to submit updates of the following documents by 11/24/2023:
LIC 500 Personnel Summary
Copy of Liability Insurance
LIC 610 Emergency Disaster Plan (If any changes)
Infection Control Plan (If any changes)
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.
SUPERVISOR'S NAME:
Hope DeBenedetti
TELEPHONE:
(707) 588-5059
LICENSING EVALUATOR NAME:
Victoria Bertozzi
TELEPHONE:
(707) 588-5087
LICENSING EVALUATOR SIGNATURE:
DATE:
10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/24/2023
LIC809
(FAS) - (06/04)
Page:
7
of
7